Wisconsin Occupational Therapy Association

New Member Application

You are on the way toward joining hundreds of other Occupational Therapy practicioners, in Wisconsin and elsewhere, as members of the Wisconsin Occupational Therapy Association.

If your intent is to renew an existing membership please ensure that you are logged-in and go to Membership Renewal.

The following information is requested as part of the membership application process. Please note that submission of your new member application does not guarantee acceptance and your application is considered to be pending further review and payment confirmation.

If you prefer to mail or fax your application please click and download the Adobe ® PDF version using the above link.

* Denotes required fields unless otherwise specified.

I. Personal InformationFirst Name:*Middle Name:Last Name:*Address:*Address 2:City:*County:*State:*

Zip Code:*Country:*

Phone:*Fax:Mobile Phone:

II. Create Login CredentialsE-mail Address:*Confirm E-mail Address:*Password:*Confirm Password:*

Your E-mail Address and Password will allow you to gain entry to member areas of the WOTA website upon review of your application.

III. District InformationWOTA District:*

Congressional District:*

Senate District:*

Assembly District:*

IV. Credentials InformationNBCOT Certified:*

Occupational Therapist (OT):*

Occupational Therapist Assistant (OTA):*

V. Miscellaneous InformationAOTA Member:*

Practice Years:*

Practice Area:*

Member Group/Dues Amount:*

Enter Referral Code:

VI. Company/Employer InformationCompany Name:*Company Address:*Company Address 2:City:*County:*State:*

Zip Code:*Country:*

Company Phone:*Company Phone Ext:Company Fax:Company Mobile Phone:Company Website:

VII. OT School Information

Information in this section is only required where you indicated "OT/OTA (Student)" in the Member Group selection above.

School Name:*School Address:*School Address 2:City:*County:*State:*

Zip Code:*Country:*

School Phone:*School Phone Ext:School Fax:School Website:

If you indicated that you are an OT/OTA student in an Occupational Therapy program in the "Member Group" selection above you must provide all requested information under this School section to be eligible for the student membership rate. The student membership rate is subject to verification of your student status and program.

VIII. Credit/Debit Card PaymentCredit Card Type:*

Name on Card:*Card Billing Address:*Card Billing City:*Card Billing State:*

Card Billing Zip Code:*Card Billing Country:*

Card Number: (numbers only)*Expiration Month:*

Expiration Year:*

Card V-Code:*

IX. Application SignatureElectronic Signature: (type your name)*

By submitting this form: (1) you affrim that all information provided is true and accurate; and (2) where you elect to make payment using a credit/debit card you authorize the Wisconsin Occupational Therapy Association to charge the credit/debit card you provide for the amount of Membership Group/Dues (section V above or that which is consistent with your credentials).

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